Organization/Person Receiving Information

Name: Sierra Native Alliance

Street Address: P.O. Box 6346

City/State/Zip: Auburn, CA 95604

Phone Number: 530-888-8767

Fax: 530-888-8757

Person/Organization Providing Information

(Examples: Participation Verification, Progress Reports; Coordination of Care; Participant/Client Request). {45 C.F.R § 164.508 (c) (iv)}
or within 1 year of signing. {45 C.F.R § 164.508 (c) (v) & Civ. Code § 56.11 (h)}

I understand my rights:

  • I authorize the disclosure of my health information as described above for the purpose(s) listed. This Authorization is voluntary, as I understand my health information is subject to Federal and State privacy regulations. {45 C.F.R § 164.508 (c) (2) (i)}
  • I have the right to revoke this Authorization in writing to the provider of this information listed above. The Authorization will stop on the date my request is received, except for action already taken, or if this Authorization was obtained as a condition of enrollment, or eligibility. {45 C.F.R § 164.508 (c)(2) (ii) & Civ. Code §56.11 (h) }
  • I understand the Notice of Privacy Practices provides instructions, should I choose to revoke my Authorization and that Authorization will automatically expire within a year of this date. {45 C.F.R § 164.508 (c) (ii)}
  • I understand that I am signing this Authorization voluntarily and that treatment, payment or eligibility for my benefits will not be affected if I do not sign this Authorization unless my treatment, enrollment in a health plan or eligibility for benefits are conditioned on me signing the Authorization. {45 C.F.R § 164.508 (c) (ii)}
  • I understand if the organization I have authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by Federal privacy regulations. {45 C.F.R § 164.508 (c)(2) (iii)}
  • I understand I have the right to receive a copy if this Authorization.

Photocopy of this Authorization shall have the same meaning as the original.